Rabinowitz Comments on Vermont’s Telemedicine Services Coverage Law

Terry Rabinowitz, M.D., professor of psychiatry and medical director of the University of Vermont/Fletcher Allen Health Care Telemedicine Program (at center), with residents at Fletcher Allen. (Photo by Raj Chawla, UVM Med Photo)

Passed during the 2012 legislative session, Section 1 of Vermont Act H.27 – Coverage for Telemedicine Services – went into effect October 1, 2012. We recently interviewed Terry Rabinowitz, M.D., D.D.S., M.S., University of Vermont professor of psychiatry and family medicine and medical director of telemedicine at Fletcher Allen, about the details and impact of this new law.Rabinowitz is co-principal investigator of the Northeast Telehealth Resource Center with the Maine Medical Care Development Public Health Division.

Q: What is telemedicine and what constitutes “telemedicine services?”Rabinowitz: Telemedicine isa method of delivering healthcare – using technology like videoconferencing – to facilitate the electronic transfer of medical information. There are basically three different types of telemedicine: live, interactive services; Store and Forward; and remote monitoring. The live, interactive format includes the doctor-patient interview. Store and Forward refers to the transfer of data from one site to another via technology, such as a camera or video recorder that stores an image like an x-ray or photo that can be forwarded via telecommunication technology to another site for a clinician to review and use to make a diagnosis or recommendation. In Store and Forward, the specialist transmits his/her opinion back to the sender. Home monitoring is the delivery of care to a patient located at their home using telemedicine technology.

Q: Which patients are most likely to use telemedicine services?Rabinowitz: Patients who will benefit from the use of telemedicine services include those for whom travel prevents them from receiving care, such as elderly, frail patients; people whose job, medical and/or financial situation make it very difficult to travel; and those who do not have access to specialty care in their area.

Q: Which insurance plans will cover telemedicine services?Rabinowitz: The bill requires that everyone – all of the commercial insurers in Vermont, Vermont Health Access, Medicaid, Doctor Dynasaur – cover telemedicine services. All of the medical services that are currently covered by an insurance plan should also be covered if delivered via telemedicine. The philosophical grounds for the law are, if you can maintain good standards of practice using telemedicine, it should be covered by insurance. The Vermont law does not require reimbursement for telemedicine services delivered to patients treated in their homes; it covers only patients receiving care in a health care facility at the time of the telemedicine service.

Q: How will reimbursable telemedicine services impact the health of rural Vermonters? Rabinowitz: Telemedicine offers appropriate care at the right time and specialty care from afar. Not all patients have to live in a rural area to receive telemedicine services, but they will need to check with their insurance company to ensure they have coverage. Vermont has a number of specialist shortages. Currently, some specialists travel to a clinic, which requires travel time. By installing software and cameras in some physicians’ computers – which can be fairly inexpensive, depending on the level of interaction required – we can get specialty care to patients who otherwise might not have access to it. Delivering care via telemedicine can also help reduce transportation costs covered by Medicaid.

Q: What services does this new law address?Rabinowitz: This law allows for physical exams to be done using telemedicine, which is unusual; only a few states that have passed this legislation allow physical exams. All of the standards of regular medical practice should be followed in telemedicine. A physician can perform an appropriate examination of the patient using instrumentation and diagnostic equipment through which images and medical records can be sent. For example, an e-stethoscope allows the physician to hear the patient’s heartbeat, etc. Technologies like this can be connected into telemedicine units. The other unique aspect of Vermont’s law is that doctors can prescribe medicine after they’ve conducted an appropriate telemedicine-based physical exam. Licensed health care providers – physicians, nurse practitioners, or any provider covered by the person’s insurance policy – should also be covered for delivering the services by telemedicine, according to the VT law. Co-pays cannot exceed what would be normal for an in-person visit.

The state doesn’t require reimbursement for telephone consults. Teledermatology and teleophthalmology are among the specialty practices that will be allowed to use Store and Forward and provide a second opinion, diagnosis and prescription based on the review of the information sent to them. Since there is a shortage of dermatologists, this technology allows a primary care provider to send a dermatologist a photo of a challenging dermatological condition, such as a rash that is not responding to treatment, along with the patient’s medical record. Then, the dermatologist can prescribe a different approach for treatment. Not all of the insurance companies in Vermont will reimburse for Store and Forward at this point. Live interactive is the focus now.